HomeMy Public PortalAbout5134 SULTANA AVE_Sewer__ DEPAUrRIB'!.YT OF COUNTY ENGINEER SEINER-,SEWAGE DISPOSAL 1
DIVISION OF BUnMING AND SAFETY PERMIT APPLICATION
1 OOUNITY OF LOM ANOWN
( WILLIAM J. FOX. Con uNENBIN[[q AOUpc86
_ FOR APPLICANTJO RLL IN LOCALITY
BUILDING NEAREST
ADDRESS S ♦ GROSS By dIr•vM /}.l14416-
LOCALITY r DISTRICT NO- GENIAL NO PERMIT NO.
NEAREST Q /R O3S.
CROSS ST
RECE D monofar Io7Faatloo DAT[ISSUED
OWNER 6 J'
MAIL
ADDRESS ��// uAtZONE OCCUPANCY MAP
_ BK PG
CITY TEL NO
CONTRACTOR0 44
_ CO.IMP NO
ADDRESS F_ JOB ND
CITY TEL NO L--j 1,
TRUNK PERMIT NO
(� ATE
REGISTRATION NO /_34 �3l{ COUNTY ROAD PERMIT NO
LEGAL
DESCRIPTION LOT NO STATE ENCROACHMENT
_ PERMIT NO
BLOCK TRACT �! S. ,S �2 WASTE APPROVAL
SIZE OF LOT MO OF BLOCS
NOW ON LOT CHARGES
USE OF
BUILDINGS e5 CONNECTION CHARGE FEE
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TOREIN BURSEMENT FEE -
PUBLIOSEWER ® $ 150 - RECEIPT NO DATE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 110
CONNECT ADDITIONAL BLDG OR- - O EXCEPTION RECORDED
WORK TO HOUSE SEWER 1 00 /
ALTER OR REPAIR EXISTING NO DATE BY
SEWER OR DISPOSAL SYSTEM 100 ---
DISCONNECT AND ABANDON SEWER
AMD/Ofl DISPOSAL SYSTEM 100 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR GRAINFIELD 7.10 [ALTER
N �ji DEPTH
P DRYWELL
SPECIAL CONDITIONS ONLY 700 �.1 / MANHOLE REFERENCE /'
/1"' I VPPIR 0 7� LOWER
E OF C
ONNECTION LENGTH FROM
OWNERS PERMIT f I ODCURB PL ML TOP L
AUTHORIZATION TOTAL FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTINGPROVALS INSPECTOWSSIONATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS _—DAY OF _19__ USE SEWER
OWNER OR CT ADDITIONAL
OWNERS AGENT ___ __ _ _ _ ____ _ _ _ _ _ _ NG OR WORK
TANK SEEP PITS)
ADDRESS R GRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI. OL❑ DRYWELL
DATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWSREPAIR SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
AMD OR LENSED CERTIFY
HEGUIRED BY LT I AN OB ANGELES PERLY GICOURNTY DISCONNECT PLUG AND
AMD STATE OF CALIFORNIA OR THAT 1 AN THE LEGAL OWN. ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKir SIGNATURE
SEEP PIT(S)0 CESSPOOL�
OFPERMITT! /
TOAOLTD 60 1/lit